Robotics in neurosurgery

7 T and beyond: toward a synergy between fMRI-based presurgical mapping at ultrahigh magnetic fields, AI, and robotic neurosurgery

Presurgical evaluation with functional magnetic resonance imaging (fMRI) can reduce postsurgical morbidity. Here, we discuss presurgical fMRI mapping at ultra-high magnetic fields (UHF), i.e., ≥ 7 T, in the light of the current growing interest in artificial intelligence (AI) and robot-assisted neurosurgery. The potential of submillimetre fMRI mapping can help better appreciate uncertainty on resection margins, though geometric distortions at UHF might lessen the accuracy of fMRI maps. A useful trade-off for UHF fMRI is to collect data with 1-mm isotropic resolution to ensure high sensitivity and subsequently a low risk of false negatives. Scanning at UHF might yield a revival interest in slow event-related fMRI, thereby offering a richer depiction of the dynamics of fMRI responses. The potential applications of AI concern denoising and artefact removal, generation of super-resolution fMRI maps, and accurate fusion or coregistration between anatomical and fMRI maps. The latter can benefit from the use of T1-weighted echo-planar imaging for better visualization of brain activations. Such AI-augmented fMRI maps would provide high-quality input data to robotic surgery systems, thereby improving the accuracy and reliability of robot-assisted neurosurgery. Ultimately, the advancement in fMRI at UHF would promote clinically useful synergies between fMRI, AI, and robotic neurosurgery.Relevance statement This review highlights the potential synergies between fMRI at UHF, AI, and robotic neurosurgery in improving the accuracy and reliability of fMRI-based presurgical mapping.Key points• Presurgical fMRI mapping at UHF improves spatial resolution and sensitivity.• Slow event-related designs offer a richer depiction of fMRI responses dynamics.• AI can support denoising, artefact removal, and generation of super-resolution fMRI maps.• AI-augmented fMRI maps can provide high-quality input data to robotic surgery systems.

Minimally-Invasive Assisted Robotic Spine Surgery (MARSS)

Minimally-Invasive robotic spine surgery (MARSS) has expanded the surgeons armamentarium to treat a variety of spinal disorders. In the last decade, robotic developments in spine surgery have improved the safety, accuracy and efficacy of instrumentation placement. Additionally, robotic instruments have been applied to remove tumors in difficult locations while maintaining minimally invasive access. Gross movements by the surgeon are translated into fine, precise movements by the robot. This is exemplified in this chapter with the use of the da Vinci robot to remove apical thoracic tumors. In this chapter, we will review the development, technological advancements, and cases that have been conducted using MARSS to treat spine pathology in a minimally invasive fashion.

Robotic Nerve Sheath Tumor Resection With Intraoperative Neuromonitoring: Case Series and Systematic Review

BACKGROUND

Retroperitoneal nerve sheath tumors present a surgical challenge. Despite potential advantages, robotic surgery for these tumors has been limited. Identifying and sparing functional nerve fascicles during resection can be difficult, increasing the risk of neurological morbidity.

OBJECTIVE

To review the literature regarding robotic resection of retroperitoneal nerve sheath tumors and retrospectively analyze our experience with robotic resection of these tumors using a manual electromyographic probe to identify and preserve functional nerve fascicles.

METHODS

We retrospectively analyzed the clinical courses of 3 patients with retroperitoneal tumors treated at the National Institutes of Health by a multidisciplinary team using the da Vinci Xi system. Parent motor nerve fascicles were identified intraoperatively with a bipolar neurostimulation probe inserted through a manual port, permitting tumor resection with motor fascicle preservation.

RESULTS

Two patients with neurofibromatosis type 1 underwent surgery for retroperitoneal neurofibromas located within the iliopsoas muscle, and 1 patient underwent surgery for a pelvic sporadic schwannoma. All tumors were successfully resected, with no complications or postoperative neurological deficits. Preoperative symptoms were improved or resolved in all patients.

CONCLUSION

Resection of retroperitoneal nerve sheath tumors confers an excellent prognosis, although their deep location and proximity to vital structures present unique challenges. Robotic surgery with intraoperative neurostimulation mapping is safe and effective for marginal resection of histologically benign or atypical retroperitoneal nerve sheath tumors, providing excellent visibility, increased dexterity and precision, and reduced risk of neurological morbidity.

THE SAFETY AND EFFICACY OF ROBOT-ASSISTED STEREOTACTIC BIOPSY FOR BRAIN GLIOMA: EARLIEST INSTITUTIONAL EXPERIENCES AND EVALUATION OF LITERATURE

Robot-assisted brain tumor biopsy is becoming one of the most important innovative technologies in neurosurgical practice. The idea behind its engagement is to advance the safety and efficacy of the biopsy procedure, which is much in demand when planning the management of endocranial tumor pathology. Herein, we provide our earliest institutional experiences in utilizing this mesmerizing technology. Cranial robotic device was employed for stereotactic robot-assisted brain glioma biopsy in three consecutive patients from our series: an anaplastic isocitrate dehydrogenase (IDH) negative astrocytoma (WHO grade III) located in the right trigone region of the periventricular white matter; a low grade diffuse astrocytoma (WHO grade II) of bilateral thalamic region spreading into the right mesencephalic area; and an IDH-wildtype glioblastoma (WHO grade IV) of the right frontal lobe producing a contralateral midline shifting. Robot-assisted tumor biopsy was successfully performed to get tissue samples for histopathologic and immunohistochemical analysis. The adjacent tissue iatrogenic damage of the eloquent cortical areas was minimal, while the immediate postoperative recovery was satisfactory in all patients. In conclusion, considering the preliminary results of our early experiences, robot-assisted tumor biopsy was proven to be a feasible and accurate procedure when surgery for brain glioma was not an option. It may increase safety and precision, without expanding surgical time, being similarly effective when compared to standard stereotactic and manual biopsy. Using this method to provide accurate sampling for histopathologic and immunohistochemical analysis is a safe and easy way to determine management strategies and outcome of different types of brain glioma.

A Historical Review of Medical Robotic Platforms

This paper provides a brief history of medical robotic systems. Since the first use of robots in medical procedures, there have been countless companies competing to developed robotic systems in hopes to dominate a field. Many companies have succeeded, and many have failed. This review paper shows the timeline history of some of the old and most successful medical robots and new robotic systems. As the patents of the most successful system, i.e., Da Vinci® Surgical System, have expired or are expiring soon, this paper can provide some insights for new designers and manufacturers to explore new opportunities in this field.

Transsphenoidal surgery using robotics to approach the sella turcica: Integrative use of artificial intelligence, realistic motion tracking and telesurgery

While full integration of robotic surgery has been achieved in other surgical domains, its transition into neurosurgery has been more prolonged, especially with respect to pituitary surgery. The confined working space and precise maneuvers required in endoscopic endonasal surgery makes development of an efficacious and safe robotic system difficult. Nevertheless, preclinical studies have attempted to demonstrate the feasibility of the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) in both transnasal and transoral approaches. In addition, unique robotics such as the concentric tube robot have been created. This system is optimized specifically for anterior skull base surgery with smaller shaft diameter arms and improved maneuverability in tight corridors. The possible role of concentric tube robotics surgery in skull base pathologies has been explored, and the novel use of telesurgery incorporated into robotic neurosurgery is discussed. An endoscopic endonasal transsphenoidal surgical system has also been developed, integrating computational methods to create a presurgical reconstructive model for surgical planning and automating the line of dissection for an enhanced approach to the sphenoid sinus. While surgical robotics for transsphenoidal surgery remain in its nascency, these preliminary findings are promising and suggest a role for robotic pituitary surgery.